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169
patients whose primary treatment will be chemotherapy and for
those patients who may have a very limited life expectancy and
time with family and loved ones.
Moreover, it reects the advancement of chemotherapy
approaches in the last few decades. Previously, resection may
have been the primary option, especially when chemotherapy was
less effective, relying on single agents like 5-uorouracil (5-FU).
However, with the advent of more potent chemotherapy regimens
incorporating agents like oxaliplatin and vascular endothelial
growth factor (VEGF) inhibitors, medical management has
become increasingly effective. This study acknowledges this
progress, demonstrating that with improved therapy, many
patients can be managed medically, avoiding the morbidity of sur-
gery. Of course, there are still cases where surgery is necessary,
particularly in patients experiencing bleeding or obstruction.
However, for asymptomatic patients or even patients with near
obstruction on imaging or endoscopy without symptoms, chemo-
therapy is a valid rst approach.
LS
What I nd interesting is that this was a single institution study,
which luckily ended up changing our practice even before pro-
spective studies were available, and subsequent prospective stud-
ies have supported its results. When this study came out, I think
that there was some debate which continued for some years. As
somebody who has operated on patients with metastatic disease, I
can attest that it is a different population. For example, there was
a previous paper from Sloan Kettering indicating that when doing
a restorative right colectomy for metastatic disease, the risk of
anastomotic leak was much higher than what we would expect
after the same operation done with curative intent. When this arti-
cle was published, referrals for palliative resections in patients
with stage IV disease became less common. I think that at least in
my practice, it was largely because of the culture instilled by the
oncology team that we ultimately evolved in our own culture as
surgeons. The oncologists are the ones who stopped referring
patients with asymptomatic disease and also stopped referring
Discussion
170
patients who could have minimal symptoms, for example, mini-
mal bleeding. Therefore, it went beyond the asymptomatic
patients described in this article, and we could sense that the
oncologists were more comfortable in starting chemotherapy and
were much less concerned that a complication would occur during
chemotherapy which could have been prevented by palliative sur-
gery. And still, sometimes, we have to intervene during chemo-
therapy, but rarely so. For a large proportion of patients with stage
IV disease, chemotherapy rst is very appropriate and helpful to
at least decrease the burden of many postoperative complications
after surgery with palliative intent.
DC
A side point this article makes is regarding Avastin. This has been
something that I have been interested in because it seemed to be a
point of contention at times or at least it was not always clear for
me. As recently as 2019, the published gastroenterology (GI) lit-
erature suggests that treatment with Avastin should not be an auto-
matic exclusion in placing endoluminal stents. So, all of that is to
say that I do not have a strong opinion against the use of Avastin
if an oncologist desires to use it.
MD
Yes, I agree with you. Another point highlighted in the article
regarding Avastin is that perforations associated with its use typi-
cally occur in areas of the bowel other than the primary tumor site.
Therefore, prophylactic resection of the primary tumor to mitigate
the risk of perforation with Avastin is not benecial. I typically
defer the decision regarding Avastin to the oncologist. The only
scenario where I actively discuss its use with oncology is for
patients who appear likely to undergo resection in the future. In
such cases, I tend to avoid Avastin to minimize concerns about
this complication during the perioperative period. Generally,
whether Avastin is used or not does not inuence my decision
regarding the necessity of an upfront operation.
24 Avoiding Surgery in Asymptomatic Patients with Stage IV…
171
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2025
D. Colibaseanu et al., Essential Articles in Colorectal Surgery,
https://doi.org/10.1007/978-3-031-77745-5_25
25
High Risk ofLocal
Recurrence Following Local
Excision ofT2 Rectal Cancer
Rothenberger DA, Garcia-Aguilar J.Role of local excision in the
treatment of rectal cancer. Semin Surg Oncol. 2000;19(4):367–75.
Abstract
Local excision (LE) of properly selected rectal cancers can pro-
vide long-term survival, with minimal morbidity, negligible mor-
tality, and excellent functional results. The role of LE has evolved
over the past century. Initially, to avoid the excessive mortality of
abdominal surgery, aggressive LE was performed to control the
symptoms of rectal cancer. As abdominal surgery became safer,
LE was restricted for use in palliation or high-risk patients. Bet-
ter preoperative tumor staging resulted in an expanded role for
LE, including curative-intent treatment of selected T1-2 rectal
cancers. Techniques for LE include snare polypectomy, transanal
excision, transanal endoscopic microsurgery, and posterior
approaches. The high local recurrence rate and compromised
survival reported in modern series, despite efforts to properly
select patients with cancers suitable for LE, have convinced the
authors to restrict the use of curative-intent LE in good-risk
patients only to the most favorable rectal cancers. Close follow-
up after LE is critical, because radical surgical salvage is usually
possible if recurrence is identied promptly. Whether adjuvant
chemoradiation can expand the role of curative-intent LE remains
controversial.
172
DC
Local excision (LE) for rectal cancer was a controversial topic 20
years ago, and it remains no less so now. The paper published in
Seminars in Surgical Oncology by Drs. Rothenberger and Garcia-
Aquilar alongside illustrates the difculty in selecting those
tumors that are appropriate for a transanal approach. They right-
fully identied that predicting the exact stage of rectal cancer is
difcult. They did a very careful inventory of the current data and
had an easy-to-follow, logical synopsis. Leaving margin-positive
tumors aside, the rst question is whether we can detect those
patients who are likely to have positive lymph nodes, because
there is no question that they should NOT have LE. Though
Magnetic Resonance Imaging (MRI) is better now, just like 20
years ago, we cannot be absolutely sure that any one specic
mesorectal lymph node is truly “negative.” Much was discussed
about adjunctive, predictive primary mass characteristics that
could put some T1 cancers into the “high risk category,” and cer-
tainly, Nivatvong’s [1, 2] and Kikuchi’s [3] contributions were
very helpful here. I think their conclusion was very appropriate:
“At present, curative-intent LE in good-risk patients is probably
best restricted to those few, highly selected, favorable early T1
rectal cancers.” We did not have sufcient information to say any-
thing more than that at the time this was written, so I think this
was an excellent synthesis of the available data at that time. They
had their own institutional study published in the same year, fol-
lowing 82 patients who had undergone LE and noted that the sur-
vival rate for the T1 patients was 98%, while it was 89% for the
T2 tumors, and the recurrence of the T1 tumors was 18% and
double that for T2 tumors. They showed that the argument of
using LE as a curative treatment for T2 tumors is a very weak
argument to make [4].
This question of LE for T2 tumors remains one that has been
doggedly pursued by multiple groups, and we will stay with one
of the two authors for this, and in 2023, we see that ACOSOG
z6041 trial results were published; here it is suggested that maybe
there are circumstances in which LE can be offered to some T2
25 High Risk of Local Recurrence Following Local Excision of T2…
173
patients. Here, 79 patients had chemoradiotherapy and LE.The
control was another study for T2 patients who had formal proctec-
tomy [5]. So already we see that it is not even reasonable to per-
form a trial in which one of the arms is LE alone for T2 patients.
At the very least, it is LE and something else; in this case, it is
54Gy of radiation concurrent with capecitabine and oxaliplatin.
The patients were carefully selected for “low risk” features which
I think was prudent.
There were two outcomes of this study that were particularly
interesting to me, and both of them were surprising. One, the
oncological outcomes were the same—essentially—as the TME
Dutch study [6], which was the surrogate control study. They have
10 years of f/u results, so I think the data is as good as it is going
to get as far as follow-up. The second outcome, also a surprise,
was that the Dutch study had better quality-of-life scores than the
LE study despite that some of the TME patients had to have per-
manent colostomies. There is a thoughtful discussion as to why
that might be, in part having to do with radiation sequelae, but the
question that is unanswerable is if the disposition of the patients
from the two different countries might be different to begin with,
culturally speaking.
And so, we do have different options for T2 tumors, and from
an oncologic perspective, one could consider LE resection, but the
question that remains…would I offer that to my patients?
References
1. Nivatvongs S, Rojanasakul A, Reiman HM, etal. The risk of
lymph node metastasis in colorectal polyps with invasive ade-
nocarcinoma. Dis Colon Rectum. 1991;34:323–8.
2. Nivatvongs S.The malignant polyp: when is enough enough?
The William C. Bernstein, M.D., Memorial Lecture. Colon
and rectal surgery: principles and practice 2000: 2000 Sept. 8;
Minneapolis, MN.
3.
Kikuchi R,
Takano M, Takagi K, etal. Management of early
invasive colorectal cancer. Risk of recurrence and clinical
guidelines. Dis Colon Rectum. 1995;38:1286–95.
Reference
174
4. Garcia-Aguilar J, Mellgren A, Sirivongs P, Buie D, Madoff R,
Rothenberger D.Local excision of rectal cancer without adju-
vant therapy: a word of caution. Ann Surg. 2000;231:345–51.
5. Lynn PB, Van der Valk MJM, Claassen YHM, et al.
Chemoradiation and local excision versus total mesorectal
excision for T2N0 rectal cancer: comparison of short-term and
long-term outcomes from 2 prospective studies. Ann Surg.
2023;277:96–102.
6. Kapiteijn E, Marijnen CA, Nagtegaal ID, et al. Preoperative
radiotherapy combined with total mesorectal excision for
resectable rectal cancer. N Engl J Med. 2001;345:638–46.
Discussion
MD
In my opinion, given the high recurrence rates post-local excision
alone, it is not a viable option for patients. Recent studies conrm
this concern. Regarding whether we determine it as T1 or T2, per-
forming a transanal excision initially allows us to assess and then
decide the appropriate management. Even if it conrms T2 with
low-risk features, recurrence rates of up to 30% necessitate fur-
ther therapy. I favor total mesorectal excision (TME), if the patient
declines chemoradiation following local excision in conrmed T2
rectal cancer cases. Despite chemoradiation potentially leading to
worse functional outcomes, if patients decline TME, the data sup-
ports this approach, and I would maintain this management
strate
gy.
LS
I think the other issue that relates to this is when pursuing TNT
and organ preservation, is whether we could treat with chemora-
diotherapy a T2N0 lesion, which obviously leads to the possibility
25 High Risk of Local Recurrence Following Local Excision of T2…
175
of overtreating a T1 lesion if misdiagnosed as a T2 lesion. If you
have an MR image that really shows the rectal wall layers and the
lesion involves the muscularis layer, but it does not go beyond
that, in my opinion, chemoradiotherapy and chemotherapy make
sense. If you have a tumor which is 3cm or smaller, you could do
a local excision and assess the staging as you pointed out, but if it
is a tumor bigger than 3 cm, especially in the low rectum, the
alternative may become an abdominoperineal resection. With the
OPRA trial indicating a 50% organ preservation rate after TNT
inlocally advanced disease, I think it is difcult to contend with
this, although there is no strong data and especially no guidelines
to support this approach.
AM
The fundamental crux of the problem is accurately determining
the pretreatment stage. Despite widely accepted practices to pur-
sue endorectal ultrasound for MR indeterminate early lesions, we
still have situations of over- or under-staging. This is where I
think the surgeon’s examination, particularly digital examination,
is critical. It is imperative to develop the experienced digital
examination and describe the tumor—is it xed? Is it mobile? In
those circumstances where imaging is uncertain, the exam can
provide additional information to guide practice.
MD
I just have signicant reservations about relying solely on
endorectal ultrasound for distinguishing between T1 and T2 stag-
ing. In my experience, it is rare to denitively classify a lesion as
strictly T1 or T2. The accuracy limitations of MRI and endorectal
ultrasound in determining T staging further complicate decision-
making. These concerns underscore the challenges in condently
assessing T1 and T2 lesions with imaging.
Discussion
176
LS
A few years ago, I had a patient with a BMI of 44kg/m
2
, with a
preoperative diagnosis of T2N0, and the tumor was not small. It
was too large for a local excision. I did an open low anterior
resection, and the pathology report was T1N0 with 25 negative
lymph nodes. And I had done a low anterior resection with an
anastomosis at four or ve cm from the anal verge, and after the
patient’s diverting loop ileostomy was taken down, the patient
developed anterior resection syndrome, and I wonder if I could
have done something different. Could this be a person ade-
quately treated with chemoradiotherapy and chemotherapy
based on cT2N0 staging? This would have been overtreatment,
but I do believe that I also overtreated the patient, let alone the
technical difculty of the operation in such a patient.
AM
Even in these circumstances where it remains unclear and radical sur-
gery is less acceptable to the patient, I think it is appropriate to pursue
transanal excision for conrmation. One can then rene their approach
and discussion with the patient based on the pathologic stage.
DC
What is interesting about this study is that the control group,
which was a Dutch cohort that had formal resection, noted a better
quality of life compared to the American interventional arm which
had chemoradiation. One could make the argument that the Dutch
people are just tougher, and the ones I know are certainly that, but
we are likely seeing the effects of radiotherapy on the rectum.
That is something to consider, and I certainly did not consider it
as seriously prior to reading this study. Oncologically, based on
the results of this study, I would not be able to guarantee the
patient that formal resection is superior to chemoradiation, or at
least I do not know for sure, and patients (in the US at least) seem
to heavily prefer avoiding radical surgery.
25 High Risk of Local Recurrence Following Local Excision of T2…
177
LS
I feel we all have patients who basically decide on their own care.
I had cases where after chemoradiotherapy and chemotherapy,
there was a residual lesion, and the patient wanted a local exci-
sion; although it did not t the criteria of the Z6041 local excision
trial, still I did a local excision; and I had a few patients who
developed terrible anal pain after local excision in a recently radi-
ated eld. This is also described and was also reported in some of
the patients in the Z6041 trial. Obviously, we are aware of the
functional limitations after low anterior resection, especially with
colo-anal anastomosis, and this includes anterior resection syn-
drome. However, the degree of disability associated with rectal
pain was very hard to witness from a caregiver’s perspective when
I encountered it for the rst time following a relatively small exci-
sion of a portion of the rectal wall. Whenever I discuss this treat-
ment strategy, on a patient with cT2N0 who returns after
neoadjuvant treatment with a residual lesion which the patient
asks me to remove transanally, I am certainly very vocal about the
risks of local excision. I feel local excision is not a walk in the
park in this particular setting, and sometimes patients come to be
evaluated having this preconceived idea that it is a simple opera-
tion, while only radical resection is complex. Having said that,
though, I also have seen the data on the MSK patients treated with
TNT who were compared retrospectively to TME patients with
respect to functional results and quality of life. The quality of life
was similar, but the functional results were better after nonopera-
tive treatment. I was trained with this idea that sphincter preserva-
tion was key, and certainly, it is so for many patients, and perhaps,
it would be for me, under similar circumstances. However, I have
also seen poor functional results associated with a technically suc-
cessful coloanal anastomosis, and I feel at times sphincter preser-
vation is not the best way to serve our patients, particularly the
older and less t individuals. Also, based on that, I believe I have
become more open to understanding the appeal of chemoradio-
therapy and chemotherapy. I think the other indication could be
for some of our patients who are morbidly obese with very low
rectal tumors. This at least gives us another option in a clinical
scenario where surgery may not result in the best outcomes and
gives the patient time to lose weight.
Discussion
179
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2025
D. Colibaseanu et al., Essential Articles in Colorectal Surgery,
https://doi.org/10.1007/978-3-031-77745-5_26
26
Transanal Minimally
Invasive Surgery (TAMIS)
forRectal Lesions
Atallah S, Albert M, Larach S.Transanal minimally invasive sur-
gery: a giant leap forward. Surg Endosc. 2010;24:2200–5.
Abstract
Background: Our novel approach is a hybrid between transanal
endoscopic microsurgery (TEM) and single-port laparoscopy that
we have termed transanal minimally invasive surgery (TAMIS).
We report the clinical application of this technique and present
preliminary data that show TAMIS to be an effective tool for
resection of both malignant and benign lesions of the rectum.
Methods: Over a 3-month period (May–July 2009), all patients
with rectal lesions who were candidates for conventional trans-
anal excision were offered the option to undergo TAMIS resec-
tion. Patients with biopsy-proven malignant lesions were required
to undergo endorectal ultrasound preoperatively to determine
tumor stage. To perform TAMIS, a single-incision laparoscopic
surgery port (SILS Port, Covidien) is introduced into the anal
canal by applying steady manual pressure. Once seated in posi-
tion, endoscopic access to the rectal vault is gained and pneumor-
ectum is established. With this access, ordinary laparoscopic
instruments, including graspers, thermal energy devices, and nee-
dle drives, are used to perform the transanal excisions.
Results: Six patients, aged 43–85 years old (mean = 59.8),
underwent TAMIS resection of rectal lesions. The average dis-